NTS Report No 2

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Centre for Non-Traditional Security Studies (NTS)

S. Rajaratnam School of International Studies

Nanyang Technological University, Block S4, Level B4,

50 Nanyang Avenue, Singapore 639798Tel: +65 6790 6982

Fax: +65 6793 2991

[email protected]

Health Governance and Dengue in Southeast Asia

NTS Report No. 2 | May 2015

Mely Caballero-Anthony1, Alistair D. B. Cook2, Gianna Gayle Herrera Amul3 and Akanksha Sharma4

1 Associate Professor and Head of the Centre for NTS Studies.

2 Research Fellow with the Centre for NTS Studies.

3 Senior Analyst with the Centre for NTS Studies.

4 Research Analyst with the Centre for NTS Studies.

www.rsis.edu.sg/nts NTS REPORT 2015


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ContentsExecutive Summary and Policy Recommendations………………………………………………………………………………………………………i

Health Governance and Dengue in Southeast Asia .................................................................................................................... 1

Introduction .................................................................................................................................................................................... 1 The Health and Socioeconomic Burden of Dengue in Southeast Asia ........................................................................................... 1

Assessing Regional Health Security Frameworks: Implications for ASEAN .................................................................................... 3 WHO Strategies: Global To Regional .......................................................................................................................................... 4 The ASCC Blueprint And Regional Dengue Prevention and Control........................................................................................... 5 Multisectoral Collaborations and Networks .............................................................................................................................. 6

Health Governance And Dengue in Indonesia ............................................................................................................................ 9

Strengths ........................................................................................................................................................................................ 9 Political: Dengue as a Priority Disease and Target Incidence Rates ........................................................................................... 9 Socio-Demographic: Mobilisation of Youth, Women and Faith-Based Organisations ........................................................ ..... 10 Technological: Dengue Vaccine Clinical Trials .......................................................................................................................... 10 Environmental: Indonesia Climate Change Trust Fund and Climate Vulnerability Mapping ................................................... 11 Legal: Dengue Outbreak Reporting System ............................................................................................................................. 12

Weaknesses .................................................................................................................................................................................. 12 Political: Limited Public Health Funding ................................................................................................................................... 12 Economic: Gaps In National-Local Health Coverage ................................................................................................................ 13 Socio-Demographic: Rural-To-Urban Migration and Health System Deficits........................................................................... 14 Environmental: Under-Utilisation of Climate Vulnerable Disease Mapping ............................................................... ............. 16

Opportunities ............................................................................................................................................................................... 17 Political: Positive Incentives and Multi-Sectoral Public Health Interventions.......................................................................... 17 Economic: Engaging Tourists and the Private Sector ............................................................................................................... 20 Technological: Biological Control of Dengue and Awareness Raising .............................................................. ........................ 21 Legal: Mosquito Breeding Fines or Local Taxes ........................................................................................................................ 22

Threats .......................................................................................................................................................................................... 23 Economic: Dengue in Tourist Areas ......................................................................................................................................... 23

Socio-Demographic: Shortage of Human Resources in Health ................................................................................................ 24 Environmental: Climate Change and Urban Heat Island Effect ............................................................. ................................... 24 Legal: Passive Surveillance System and Lack Of Evaluation ..................................................................................................... 26

Health Governance And Dengue In Malaysia ............................................................................................................................ 27

Strengths ...................................................................................................................................................................................... 28 Political: Government Programmes and Interventions .............................................................. .............................................. 28 Economic: Health Budget Significant as Percentage of GDP ................................................................. ................................... 29 Legal: Legislative Framework for Diseases ............................................................................................................................... 30

Weaknesses .................................................................................................................................................................................. 30 Environmental: Rural-To-Urban Migration and Natural Habitat Erosion................................................................................. 27 Legal: Limited Scope of Regulatory Framework ....................................................................................................................... 27

Opportunities ............................................................................................................................................................................... 28 Political: Positive Incentives and Multi-Sectoral Public Health Interventions.......................................................................... 28 Economic: Potential Activation of Tourism Sector .......................................................... ......................................................... 29 Legal: Mosquito Breeding Fines or Local Taxes ........................................................................................................................ 29

Threats .......................................................................................................................................................................................... 35 Environmental: Poor Communication and Weak Inspection Regime ...................................................................................... 35 Socio-Demographic: Accelerating the Spread of Dengue ........................................................................................................ 35 Capacity: Ineffective Implementation and Governance .......................................................................................................... 36

Policy Recommendations ......................................................................................................................................................... 38

References ............................................................................................................................................................................... 40

Annex ....................................................................................................................................................................................... 43

Actors and stakeholders in dengue prevention and control in Indonesia ............................................................ ........................ 43 Actors and stakeholders in dengue prevention and control in Malaysia ..................................................................................... 44


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i

Executive Summary and Policy Recommendations

This Report focuses on health governance of vector-borne diseases in Southeast Asia, analysed from thecontext of threats and opportunities brought about by climate change, urbanisation and globalisation. It firstdiscusses regional health governance in ASEAN and the mechanisms and frameworks that have beenestablished to promote health security, with particular focus on vector-borne diseases. It then provides abackground on dengue in Southeast Asian countries, the economic burden of the disease and the regionalprevention and control measures that have been implemented so far. The Report also presents a SWOTanalysis that assesses the health governance systems of two Southeast Asian countries – Indonesia andMalaysia – with a particular focus on the institutions, networks and the effectiveness of domestic vectorprevention and control measures. It assesses the level of integration that regional frameworks anddomestic measures have achieved and policy shifts from reactive towards preventive and sustainable longterm solutions. Finally, the Report lays out a number of policy recommendations relevant to regionaldengue prevention and control.

Introduction

Dengue is one of the most common vector-borne diseases in Southeast Asia,5 and has been ranked as themost important mosquito-borne viral disease with epidemic potential in the world. Among all the vector-borne viral diseases, the transmission rate of dengue is the fastest in the world. It is alarming that dengueepidemic cycles in the region have been reduced to 3 to 5 years from the average 10 year cycle. Well-integrated prevention and control programmes to combat the dengue across all levels and across differentsectors and among stakeholders is essential. It is estimated that with the annual average 2.9 milliondengue episodes in Southeast Asia, the annual economic burden in aggregate costs from 2010 data isestimated at USD950 million or about USD1.55 per capita (Shepard, Undurraga and Halasa 2013).

Convergence of Regional Frameworks and Multi-sectoral Initiatives

There are existing intergovernmental strategies from global and regional actors and multisectoralcollaborations and networks that form part of the ASEAN regional health security framework, particularlystrategies that deal with communicable disease control. Specifically, the regional health security frameworkfor dengue puts the region in a good position to leverage on collaborative mechanisms for effective dengueprevention and control. ASEAN member states are very much aware of the epidemic potential of dengueand given its numerous and porous borders, there have been regional efforts to stem dengue under variousinitiatives under the ASEAN community building processes set forth by the ASEAN Charter and the ASEANSocio-Cultural Community Blueprint (ASCC).

On one hand, there are intergovernmental initiatives such as the Asia Pacific Strategy for EmergingDiseases (APSED), the WHO Asia Pacific Dengue Strategic Plan and the ASEAN Medium Term Plan onEmerging Infectious Diseases (2012-2015) which mandates the observance of the ASEAN Dengue Day.

The ASEAN Strategic Framework for Health Development and the Expert Group on CommunicableDiseases further puts focus on endemic vector-borne diseases such as dengue and malaria. On the otherhand, there are a number of multi-sectoral collaborations and networks in Southeast Asia. In line with the ASCC Blueprint’s action line to “strengthen and maintain surveillance system for infectious diseasesincluding malaria and dengue fever [among others],” there is the United in Tackling Epidemic Dengue(UNITEDengue) network focused on the cross-border sharing of dengue surveillance information andknowledge on dengue control. The network’s website, hosted by the Singapore Environmental HealthInstitute provides its members up-to-date disease incidence, virus surveillance information and a lucid keyfor mosquito identification.

With regard to the ASCC Blueprint’s action line to “promote collaboration in research and development onhealth products especially on new medicines for communicable diseases including neglected diseases

5 Southeast Asia refers to the ASEAN region which includes: Brunei Darussalam, Cambodia, Indonesia, Lao People's Democratic Republic, Malaysia, Myanmar,

Philippines, Singapore, Thailand and Viet Nam.


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commonly found in ASEAN Member States,” there are initiatives toward dengue vaccine development andbiological vector control. There are three main collaborations on dengue vaccines in the region, theDengue Vaccine Initiative (DVI), the ASEAN Network for Drugs, Diagnostics, Vaccines and TraditionalMedicines Innovation (ASEAN-NDI) and the ASEAN Member States Dengue Vaccination AdvocacySteering Committee (ADVASC). Another research program, Eliminate Dengue, aims to biologically controldengue by studying how Wolbachia bacteria can be utilised as an effective strategy to disrupt denguetransmission between people by targeting the dengue virus transmission by Aedes aegypti mosquitoes. In

line with the ASCC Blueprint action line to “strengthen regional clinical expertise through professionalorganisations networks, regional research institution, exchange of expertise and information sharing,” thereare a number of existing networks including the Southeast Asia Infectious Disease Clinical ResearchNetwork (SEAICRN), the Inter-Islamic Network in Tropical Medicine (INTROM) and the Southeast AsianMinisters of Education Organization - Tropical Medicine and Public Health Network (SEAMEO-TROPMED).

Indonesia

There is an increasing diversity of actors and stakeholders involved in health governance and dengueacross the archipelago. Dengue prevention is not wholly limited to government actors but also is slowlybeing integrated into the objectives of the private sector, academia, non-government, faith-based andcommunity-led organisations, international funding agencies, pharmaceutical companies and regionalorganisations. However, the health system including infrastructure and human resources are stillinadequate. Improvements on this front, especially recruiting more health professionals into the publicsector and retaining them are critical. There is potential for improvement in dengue prevention and controlin Indonesia. Political will, community leadership and private sector initiatives can all help in supporting andstrengthening public and environmental health across all provinces and special autonomy areas. Long-termcommitments for dengue prevention and control are also needed, as many initiatives are usually project-based and most of them are not properly monitored and evaluated. Some local pilot projects weresuccessfully scaled up but not on a national scale as a result of limited financial resources.

Malaysia

A recent increase in dengue incidence is a significant cause of concern, especially given thehyperendemicity of serotypes. The 2009 – 2013 National Strategic Plan for Dengue included a commitmentto half the total number of cases by 2013 but was not achieved. Greater urbanisation has led to an increasein encroachment on natural habitats and this could lead to greater co-habitation between mosquito vectorsand humans. Thus, there should be further investigation into more sustainable land-use strategies. Morerecently, the Malaysian government has implemented prevention and control measures at the local level aswell as policy measures at the state level. One commendable national level measure was the creation of aDengue Task Force headed by the Deputy Prime Minister in July 2014. However, while the government’sprogrammes are well-designed especially in terms of engaging different actors, improvements are neededin terms of infrastructure and human resources investment in rural areas. Further development ofcommunity and faith-based organisations can help to spread awareness regarding dengue prevention andcontrol measures particularly in rural areas. Alongside this investment, higher levels of engagement with

the private sector, especially in the tourism and food & beverage sector to share best practices wouldencourage a more consistent culture of prevention and control.


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Policy Recommendations

This NTS Report provides an initial assessment of regional dengue interventions and an examination ofIndonesia and Malaysia in dengue prevention and control. From a regional perspective, multilateralarrangements can provide an avenue to develop cooperative responses to emerging and acceleratedspread of communicable diseases as a result of urbanisation, the movement of people and climate change.Below are some policy recommendations for ASEAN:

Utilise and reinforce established APSED and APT mechanisms to achieve IHR core capacities.

Integrate the UNITEDengue mechanism into the post-2015 ASEAN framework.

Promote new diagnostic technology in dengue confirmation and infection across ASEAN.

Promote more public-private partnerships in dengue vaccine development.

Stimulate the expansion of the collaborative clinical research network of hospitals and research

institutions to further strengthen regional clinical expertise on dengue.

Encourage climate data use to support early warning systems and dengue prevention and control.

Promote dengue prevention and control as a component of corporate social responsibility especially in

the tourism sector.

Scale up efforts to biologically controlling dengue.

Advocate for a World Dengue Day, building on the success of ASEAN Dengue Day.


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Health Governance and Dengue in Southeast Asia

Introduction

Dengue is one of the most common vector-borne diseases in Southeast Asia, and has been ranked as themost important mosquito-borne viral disease with epidemic potential in the world (WHO, 2014). Among all

the vector-borne viral diseases, the dengue transmission rate is the fastest in the world. It is concerningthat dengue epidemic cycles in the region have reduced to three to five years from the average ten yearcycle. A well-integrated dengue prevention and control programme across all levels, sectors and amongstakeholders is essential. This Report first assesses regional health security frameworks and the state ofthe regional approach to dengue prevention, control and elimination as a means to further developsustainable and effective dengue policy measures. The Report then examines dengue prevention andcontrol measures undertaken at the national and local levels in Indonesia and Malaysia. With a SWOTanalysis, it aims to qualitatively assess existing prevention and control measures, including the impact ofclimate change on vector-borne diseases, as well as the link between urbanisation and dengue, and thetransboundary health risks and threats due to migration patterns. In summary, this Report provides someinsights on the implications of the dengue responses in local health systems and at the regional level toaddress vector-borne diseases.

The Health and Socioeconomic Burden of Dengue in Southeast Asia

In Southeast Asia, combined mortality and morbidity (DALYs6) due to dengue is estimated at 436,000 in2000 and at 606,000 in 2012 (Global Health Estimates 2014). Dengue is an Aedes aegypti mosquito-borneviral disease that mainly causes flu-like symptoms including fever, headache, eye pain, muscle and jointpain and only shows symptoms in an infected person after three to fourteen days. About seventy-five percent 7 of dengue virus carriers do not manifest symptoms, are not identified through public healthsurveillance and unknowingly become virus transmitters (Bhatt et al. 2013). The WHO (2014) highlightsthat most vector-borne diseases like malaria and dengue fever have long been associated not only withclimate and humidity but also to access to safe drinking water and sanitation policies as well as urban

development that impacts land use, deforestation, water resource management, settlement siting andhouse design. All these environmental determinants of health evolve into risks when exacerbated byconditions brought about by extreme weather.

In ASEAN, Lao PDR, Indonesia and the Philippines bear the highest dengue burden as of 2012 (See Table1 below). The most comprehensive study on the economic cost of dengue in Southeast Asia so far is thatof Shepard, Undurraga and Halasa (2013), which focused on the cost of dengue episodes, excludingprevention and vector control from 2001 to 2010. Shepard et al. (2013) estimated that with the annualaverage 2.9 million dengue episodes in Southeast Asia, the annual economic burden in aggregate costsfrom 2010 data is estimated at USD950 million or about USD1.55 per capita. Indonesia has the highesteconomic burden of dengue in terms of aggregate cost, with about 34 per cent of the total regionaleconomic burden of dengue, followed by Thailand (30 per cent) and Malaysia (13.5 per cent) (See Figure

1). However, in terms of cost per capita, Singapore bears the highest burden, followed by Malaysia andThailand (See Figure 2).

6 Disease burden is measured by the World Health Organization in terms of disability-adjusted life year (DALY) or one lost year of healthy life .DALYs measure

the overall disease burden in terms of number of years lost due to ill-health, disability or early death. One DALY is equivalent to one lost year of healthy life. It is

calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with

the health condition. The YLL basically correspond to the number of deaths multiplied by the standard life expectancy at the age at which death occurs. To

estimate YLD for a particular cause in a particular time period, the number of incident cases in that period is multiplied by the average duration of the diseaseand a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). Source: Health statistics and information systems,

Metrics: Disability-Adjusted Life Year (DALY), http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/

7 Bhatt et al estimated about 290 million inapparent infections from 390 million infections of which only 96 million cause apparent dengue infections.


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Figure 1. Annual Aggregate Cost of Dengue (in USD thousand)

Source: Shepard, Undurraga and Halasa 2013

Figure 2. Annual Cost of Dengue per capita (in USD)

Source: Shepard, Undurraga and Halasa 2013


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Table 1: Combined mortality and morbidity (DALY) due to dengue (2000, 2012) and economicburden of dengue in Southeast Asia (aggregate and per capita)

Country Population2012

DALYs2000

DALYs2012

Aggregate Cost2010

(in USD)

Cost per capita (inUSD)

ASEAN 610,325,000 436,000 605,500 949,281,000 1.55

Indonesia 246,864,000 173,200 142,100 323,163,000 1.31

Thailand 66,875,000 8,800 9,500 290,028,000 4.34

Malaysia 29,240,000 6,400 8,400 127,973,000 4.38

Philippines 96,707,000 92,800 94,600 80,829,000 0.83

Singapore 5,303,000 1,200 1,600 67,090,000 12.65

Vietnam 90,796,000 49,300 40,000 23,453,000 0.25

Cambodia 14,685,000 63,800 35,000 16,540,000 0.11

Myanmar 52,797,000 35,600 26,200 14,476,000 0.27

Lao PDR 6,646,000 4,900 248,100 5,093,000 0.77Brunei 412,000 0 0 636,000 1.54Sources: World Health Organization 2014; For Brunei, data for DALY reflects 2010 data and was derived from Shepard et al. 2013

Assessing Regional Health Security Frameworks: Implications for ASEAN

Since the SARS epidemic in 2003, regional health security strategies have tended to prioritisecommunicable diseases that have epidemic potential (Caballero-Anthony and Amul 2015). Ascommunicable diseases have high health and socioeconomic burdens, dengue cooperative strategies andframeworks have developed in the region. As such, intergovernmental strategies from global (World HealthOrganisation) and regional (ASEAN) actors to multi-sectoral collaborations and networks are all part of theregional health security framework for dengue. One co-benefit is the growth of multi-sectoral collaborations

to combat dengue that has been noteworthy so far in terms of capacity building and innovation. One way toutilise this is to mobilise funding for innovative and sustainable strategies against dengue involvinggovernments, the pharmaceutical industry, the private sector and non-government organisations through afocal point such as a regional dengue ambassador.

There has been emphasis given to prioritising dengue control activities at a regional level mainly becauseof geographical proximity (Spiegel et al. 2005, 280). Increasing globalisation has led to larger movementsof people, improved modes of transportation and hence greater interconnectivity between endemic andnon-endemic countries. Although dengue prevention and control is focused at the community level,transmitting dengue from one country to another is easy, as tourists can travel by trains, boats, buses oraeroplanes. Southeast Asian governments are very much aware of the epidemic potential of dengue andgiven its numerous and porous borders, there have been regional efforts to stem dengue under the ASEANcommunity building processes contained in the ASEAN Charter and the ASEAN Socio-Cultural Community(ASCC) Blueprint. The main challenge for intergovernmental health security frameworks is fundingsustainability. As many strategies aim to contribute to the aspirations of the ASEAN Socio-CulturalCommunity of the wider ASEAN Community by 2015, the progress and targets of these strategies andinterventions need to be reviewed. Such a review can help funding agencies, national governments andnon-state actors to prioritise and earmark funding not only for dengue prevention and control but also forvaccine research and development. This report aims to provide an initial assessment of these regionalinterventions.

WHO Strategies: Global to Regional

From a global health perspective, it is important to consider the work of the WHO and its regional offices onvector-borne diseases. It has already laid out the necessary regional and global frameworks for dengueprevention and control. The WHO’s Global Strategy for Dengue Prevention and Control (2012 -2020)


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highlights reducing the dengue burden by at least 50 per cent in terms of mortality and at least 25 per centin terms of morbidity by 2020 (WHO 2012). The WHO presence in the region is spearheaded by itsWestern Pacific Regional Office (WPRO) and the Southeast Asia Regional Office (SEARO). These haveinitiatives spanning communicable diseases, family health and research, health systems development, andsustainable development and healthy environment. WPRO and SEARO developed a bi-regional DengueStrategic Plan for the Asia-Pacific Region 2008-2015 based on the Strategic Framework for the Asia PacificDengue Partnership, which forms part of the WHO Global Strategy, the Asia-Pacific Dengue Strategic Plan

(2008-2015).Figure 1 WHO Framewo rk for Dengue

This is further supported by the Asia Pacific Strategy for Emerging Diseases (APSED), another bi-regionalstrategy aimed at ‘strengthening national and regional capacities to manage and respond to emergingdisease threats, including dengue.’ The APSED addresses the capacity-building requirements mandated bythe revised 2005 International Health Regulations (IHR) (See Figure 1). The IHR has included dengue asone of the diseases that may constitute a public health emergency of international concern (PHEIC) withimplications for health security due to disruption and rapid epidemic spread beyond national borders (WHO2009). In 2013, under the APSED, the WHO WPRO with WHO collaborating centres including theEnvironmental Health Institute of Singapore, established an External Quality Assessment (EQA)programme for dengue and successfully conducted the programme in 19 national public health laboratoriesin the region, where 84 per cent were able to accurately detect dengue virus and antibodies.

The ASCC Blueprint and Regional Dengue Prevention and Control

ASEAN forms the main regional health security framework in Southeast Asia, particularly through itsStrategic Framework for Health Development. The Expert Group on Communicable Diseases serves as themain health subsidiary body tasked with planning regional interventions on communicable diseasesincluding dengue. For the specific disease component on dengue, there is the ASEAN Dengue Day underthe ASEAN Medium Term Plan on Emerging Infectious Diseases (2012-2015). Since 2011, the Southeast Asian regional entity has been observing ASEAN Dengue Day alongside their national dengue day to raisepublic awareness. This was in line with the 2011 Jakarta Call for Action on the Control and Prevention ofDengue to strengthen regional cooperation through: “enhancing regional preparedness and capacitystrengthening national and regional alert and response capacities; sharing information, experiences and

best practices in improving access to primary health care by people at risk and; encouraging the closecollaboration and creating networks among the public and private sectors and civil society.” The 2014 ASEAN Plus Three (APT) Partnership Laboratories Work Plan now includes facilitating pathogeninformation sharing for dengue virus serotypes, enterovirus genotype and multi-drug resistant tuberculosis.The APT Field Epidemiology Training Network (FETN) has also initiated collaboration in developing casestudies on dengue outbreak investigation, hosted by Singapore in 2011.

InternationalHealth

Regulations(Revised,

2005)

GlobalStrategy for

DenguePrevention

and Control,2012-2020

Asia PacificStrategy for

EmergingDiseases(APSED,

2010)

Asia PacificDengue

StrategicPlan (2008-

2015)


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Figure 2: ASEAN Framework fo r Communicable Diseases

The ASCC Blueprint (2009) has several action lines related to dengue, specifically under objective B5:Improving capability to control communicable diseases. This includes initiatives to “consolidate, furtherstrengthen and develop regional cooperative arrangements through multisectoral and integratedapproaches in the prevention, control, preparedness for emerging infectious diseases in line withInternational Health Regulation 2005 and the Asia Pacific Strategy for Emerging Diseases (APSED).”

Despite the WHO-led Asia Pacific Strategy for Emerging Diseases (APSED) that supported ASEANprogrammes for capability building in communicable disease control, the International Health Regulation(IHR) core capacity gaps within ASEAN remain of substantive concern. Based on the ASCC Blueprintobjective, the less developed CMLV group needs to be integrated with the more developed ASEAN6(Brunei, Indonesia, Malaysia, Philippines, Singapore and Thailand). In terms of the eight core capacities,Cambodia, Myanmar, Laos and Vietnam (CMLV) as a group is almost on par on average with the ASEAN6group on surveillance and legislation, but the gap in terms of coordination, preparedness, response,laboratory and human resources is still substantial (see Figure 1). The CMLV group is also almost at parwith ASEAN6 in terms of zoonosis and food safety, but it still has considerable capacity-building needs forchemical and radionuclear health hazards and public health events at points of entry (see Figure 2).8 Gapsin critical capacities such as coordination and preparedness, and capabilities for public health events atpoints of entry pose serious threats to regional health security, as migration occurs within and across

borders posing challenges to the prevention and control of vector-borne diseases such as dengue andmalaria.

8 This analysis and the corresponding figures were originally published in “Reinforcing Health Security in ASEAN” (Centre for Non-Traditional Security (NTS)

Studies, 2015).

A S E A N S t r a t e g i c F r a m e w o r k o n H e a l t h

D e v e l o p m e n t Health Ministers'

Meeting (AHMM)

+

Senior Officials' Meetingon Health Development

(SOMHD)

Expert Group onCommunicable Diseases

ASEAN Plus ThreeMechanisms

Partnership

Laboratories

Field EpidemiologyTraining Network

Emerging InfectiousDiseases Programme

Risk Communication

Human and AnimalHealth Collaboration

Specific Diseasesincluding Rabies, Dengue

and Malaria

Minimum Standards ofJoint Multi-sectoral

Outbreak Investigationand Response

Stockpiling of Anti-viraland Personal Protective

Equipment

WHO-EC Project onHighly Pathogenic Re-

/Emerging Diseases


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Multisectoral Collaborations and Networks

There are a number of multi-sectoral collaborations and networks in Southeast Asia. In line with the ASCCBlueprint’s action line on infectious disease surveillance, there is the United in Tackling Epidemic Dengue(UNITEDengue), which was jointly founded by the Ministry of Health (Malaysia), the National Environment Agency’s Environmental Health Institute (Singapore) and the Universitas Andalas, Padang, West Sumatra(Indonesia). 9 The network’s focus is cross-border sharing of dengue surveillance information and

knowledge on dengue control via the network’s website.

The ASCC Blueprint’s action line to “promote collaboration in research and development on health productsespecially on new medicines for communicable diseases including neglected diseases commonly found in ASEAN Member States,” covers initiatives toward dengue vaccine development and biological vectorcontrol. There are three main collaborations on dengue vaccines in the region, the Dengue VaccineInitiative (DVI), the ASEAN Network for Drugs, Diagnostics, Vaccines and Traditional Medicines Innovation(ASEAN-NDI) and the ASEAN Member States Dengue Vaccination Advocacy Steering Committee(ADVASC). The DVI, a consortium of organisations10 aimed towards dengue vaccine decision making andintroduction in endemic areas, came into being through the 2001 Pediatric Dengue Vaccine Initiative. The Asia Pacific Dengue Prevention Board is composed of medical and public health experts from theUniversity of Indonesia’s Faculty of Medicine, University of Malaya Medical Centre’s Faculty of Medicine,

Singapore’s DSO National Laboratories, the Vaccine Trial Center at the Mahidol University’s Faculty ofTropical Medicine, the National Epidemiology Center of the Department of Health in the Philippines, theDepartment of Medical Research in Myanmar and the Institut Pasteur du Cambodge in Cambodia, amongothers (Dengue Vaccine Initiative 2015).

In 2009, the ASEAN-NDI was founded to promote research and development, to develop North-South andSouth-South partnerships to support capacity-building and to establish strategic research networks, in linewith the objectives of the WHO Global Strategy and Plan of Action on Public Health, Innovation, andIntellectual Property (GSPA-PHI). It was adopted by the ASEAN Committee on Science and Technology

9

Other members include the Ministries of Health of Brunei, Cambodia, Philippines, Thailand, Vietnam and Sri Lanka, as well as the Chief Minister Secretariat ofPakistan and the Aga Khan University (Karachi, Pakistan) (WHO and NEA, 26 August 2014; UNITEDengue 2014).

10 These organisations include the International Vaccine Institute, the WHO Initiative for Vaccine Research, International Vaccine Access Center of the Johns

Hopkins University Bloomberg School of Public Health, The Sabin Vaccine Institute.

Figur e 3. IHR Core Capacity Gaps betw een

ASEAN6 and CMLV (2013)

Figu re 4. Gaps in Capacity f or Health Hazards

and Publ ic Health Events at Points of Entry

between ASEAN6 and CMLV (2013)

Source: World Health Organization, Global Health Observatory Data,2013

Source: World Health Organization, Global Health Observatory Data,2013


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(COST) as its own initiative through the ASEAN Sub-Committee on Biotechnology. 11 It maintains adatabase on drug, diagnostics, vaccine and traditional medicine development for dengue, and otherdiseases in the region (ASEAN-NDI 2011). There is also the ASEAN Member States Dengue Vaccination Advocacy Steering Committee (ADVASC), a regional independent scientific and educational committee thataims to disseminate information and come up with practical recommendations in preparing for the denguevaccine introduction in ASEAN countries established in 2011, and supported by an educational grant fromSanofi Pasteur. In 2014, it published a number of recommendations on how to streamline and harmonize

surveillance and diagnostic capacities in ASEAN as well as the need to reconcile and harmonize thedifferent WHO guidelines in terms of dengue case definition and surveillance (Thisyakron et al. 2014).

There is also the Eliminate Dengue research program that aims to biologically control dengue, particularlyits vectors. According to the Eliminate Dengue website (2015), the program enjoys community andregulatory support as a scientific and multi-sectoral collaboration which brings together scientists from Australia, Brazil, Colombia, Indonesia and Vietnam, as well as philanthropic groups such as the Bill andMelinda Gates Foundation, Wellcome Trust, the Tahija Foundation in Indonesia, the Australian federal andQueensland state governments among others. The research program is studying how Wolbachia bacteriacan be utilised as an effective strategy to disrupt dengue transmission between people by targeting thedengue virus transmission by Aedes aegypti mosquitoes. In line with the ASCC Blueprint action line to“strengthen regional clinical expertise through professional organisations’ networks, regional researchinstitution, exchange of expertise and information sharing,” there are a number of existing networks including the Southeast Asia Infectious Disease Clinical Research Network (SEAICRN), the Inter-IslamicNetwork in Tropical Medicine (INTROM) and the Southeast Asian Ministers of Education Organization -Tropical Medicine and Public Health Network (SEAMEO-TROPMED). The SEAICRN is one of the mostsuccessful collaborative clinical research networks of hospitals and research institutions in Thailand,Vietnam and Indonesia supported by the National Institutes of Allergy and Infectious Diseases (US) and theWellcome Trust (UK) and founded in 2005. The SEAICRN has been instrumental in improving the quality ofclinical laboratories in the region with a programme to have each hospital clinical laboratory accredited bylocal and international bodies. The network also enabled the renovation of a number of laboratories tohouse a molecular diagnostic laboratory (MDL), and staff training in molecular diagnostics and externalquality assurance (EQA) programmes. All hospitals equipped with such laboratories are encouraged to use

the MDL for dengue testing (Wertheim et al. 2010; SEAICRN, 2015). There is also the INTROM,established under the Organisation of Islamic Cooperation to promote collaborative research and training intropical medicine among Muslim countries.

In 2014, it held a tropical medicine workshop on the “Epidemiology and Identification of Dengue Vectorsand Detection of the Virus in Vectors and Humans” to develop capacity-building in vector epidemiology,laboratory capacity and technology (Institute of Medical Research 2014). Lastly, SEAMEO-TROPMED is anetwork of regional higher education centres, training and research in tropical medicine and public health,based in three sub-regional centres in Malaysia (microbiology, parasitology and entomology), thePhilippines (public health, hospital administration, environmental and occupational health) and Thailand(tropical medicine) (SEAMEO TROPMED 2015).

11 In 2014, it published the results of its “Mapping of Product R&D Landscape for Infectious Tropical Diseases in ASEAN Member States” and identified five major

academic and university-associated dengue research centres in ASEAN, including the Laboratory of Molecular Virology, Institute of Molecular Biosciences of theMahidol University in Thailand, the Oxford University Clinical Research Unity at the Hospital for Tropical Diseases in Vietnam, the Tropical Infectious Diseases

Research and Education Center (TIDREC) of the University of Malaya, the Duke-National University of Singapore Graduate Medical School in Singapore and the

School of Biological Sciences at the Nanyang Technological University in Singapore (Montoya et al. 2014).


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Figure 5. Mult isectoral col laborat ions and network s on deng ue in Southeast Asia

With many of these regional health security frameworks and mechanisms established to countercommunicable diseases after the SARS epidemic, the region is already well positioned to leverage onthese for more effective dengue prevention and control. However, policy frameworks can be encumberedby a number of risk factors that affect dengue incidence in the region. The following section presents ananalysis of the strengths, weakness, opportunities and threats to health governance in relation to dengue inIndonesia and Malaysia. It provides a brief stocktaking of what these countries have implemented in termsof accomplishing global and regional targets.


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Health Governance and Dengue in Indonesia

Dengue is hyperendemic in Indonesia and all four serotypes are co-circulating in all of its 34 provinces (See Annex A). It ranks as the most vulnerable in Asia among dengue-endemic countries, followed by Vietnam,Thailand, the Philippines and Malaysia (Fullerton et al. 2014). Dengue is the most common cause of febrileillness requiring hospitalisation in Indonesia but hospital diagnostic testing still needs improvement (AFIREStudy Team 2014). Since the first dengue cases were reported in Jakarta and Surabaya in 1968, it hasbeen included in the national disease surveillance system and is reported in the form of cases, outbreaks orclinical and virological studies. Dengue cases can either be suspected, probable or confirmed. Onlyprobable (with supportive dengue serology from blood specimen or with an epidemiological link to aconfirmed dengue case) and confirmed (through virus isolation or detection of viral antigen or RNA inserum) are reported to the Communicable Disease Center of the Ministry of Health by district healthauthorities and further reflected in the surveillance database (Karyanti et al. 2014, 412). To support andimprove serotype surveillance, the MOH has established seven sentinel surveillance stations acrossIndonesia – North Sumatra, Medan, East Kalimantan, Yogyakarta, Manado, Maluku and Mataram.12 Thefollowing section outlines and discusses the findings from a SWOT analysis that looks into Indonesia’shealth governance in relation to dengue, in terms of political, economic, socio-demographic, technological,environmental and legal factors. This SWOT Analysis is based on desk research during the research period

from October 2014 to March 2015 and on key informant interviews conducted in Jakarta, Indonesia from 5to 9 December 2014.

Box 1. Dengue/DHF in Indonesia

Annual DHF incidencea 0.05/100,000 in 1968 to 28/100,000 in 2014

Dengue Virus Serotypesb

DENV-1: genotypes I and IV (most common)DENV-2: cosmopolitanDENV-3: genotypes I and VDENV-4: genotype II

Annual dengue economic and disease burdenc142,100 (DALYs, 2012)USD323,163 million (in medical costs, 2010)

Sources: a. Tan et al. 2014; b. Eijkman Institute of Microbiology, 2014; c. Shepard et al. 2014

Strengths

Political: Dengue as a priority disease and target incidence rates

As one of the priority diseases in Indonesia, there is a gamut of public health programmes andinterventions for dengue prevention and control at the national level. National public health programmes fordengue are led by the Directorate on Disease Control and Environmental Health in the Ministry of Health(MOH), with the Arbovirus and Environmental Health sub-directorates directly involved in policy planningand implementation of dengue prevention and control initiatives. In terms of policy planning, the MOH leadsthe inter-ministerial national Working Group on Dengue Haemorrhagic Fever or POKJANAL DBD. 13

Meeting biannually since 1995, the national working group provides the integrated supervisory, advisoryand planning of dengue prevention, control and surveillance strategies.14 From 2010 to 2014, Indonesia’s Ministry of Health carried out intervention programmes and pilot projects as part of its 2010-2014 StrategicPlan, which included the 3M Plus source reduction and prevention programme; vector surveillance throughroutine larvae monitoring ( jumantik ) programme; vector mapping and epidemiological surveillance;establishing the KLB as an early warning system; produce national guidelines for dengue prevention andcontrol in schools and for larvae monitoring and inspection; and awareness raising campaigns15 such as thecommunication for behavioural impact (COMBI) projects, Clean Friday Movement and the annualobservance of the Dengue Day which coincides with the ASEAN Dengue Day.

12 Interview with Indonesian official, Jakarta, 8 December, 2014

13 The POKJANAL DBD is composed of of the following ministries and agencies: education, environment, home affairs, housing and infrastructure, women

empowerment welfare group, religious affairs, police, attorney general, tourism and transportation, as well as professional organisations and communityorganisations (Interview with Ministry of Health official, Indonesia, by Gianna Gayle Herrera Amul, 8 December 2014).

14 Interview with WHO official, Jakarta, 5 December 2014

15 Interview with Indonesian officials, Jakarta, 8 December 2014


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Indonesia has successfully reached its target incidence rate from its 2010 baseline but its target incidencerate reduction is less ambitious than expected. Based on the annual incidence rates and the nationally-settarget incidence rate of 50/100,000 by the end of 2014 (See Figure 3), Indonesia has successfully reducedits incidence rate from the baseline of 86/100,000 in 2010 to 28/100,000 in 2014. However, thegovernment’s strategic plan follows a high baseline. The 2010 baseline coincides with the highest peak ofincidence in the local dengue epidemic cycle over the past ten years. It is also notable that the government

only aims to reduce the incidence rate by 1/100,000 per year illustrating the lacklustre national dengueprevention and control plan.

Socio-demographic: Mobilisation of youth, women and faith-based organisations

Young people, students, faith-based, community and women’s organisations are mobilised for mosquitolarvae inspection in households and localities. Aside from primary schools, local political authorities, districtand community health centres, environmental affairs departments and public utility departments at thedistrict and city levels, a number of actors are further incorporated into dengue prevention and control,particularly vector control through larvae inspection and elimination. Ther e are the women’s associations(PKK), representatives of community environmental health forums (forum lingkungan) and non-governmentorganisations that can be utilised (Tana et al 2012). Most of these organisations are already integrated into

the district level working group on DHF (POKJANAL DBD). One example of community-based vectorcontrol is the 1997 Piket Bersama campaigns16, which led to the formation of dasawisma (ten-house)groups, led by the housewives, mothers or wives of local authorities or from PKK, organised to take turns ininspecting each other’s households on a weekly basis (Kusriastuti et al. 2004; Spiegel et al. 2005). Thispractice has since been institutionalised into the mosquito larvae monitoring ( jumantik ) programme andintegrated into the government’s 3M Plus strategy.

Figu re 6: Target and A ctu al Incidenc e and Case Fatality Rates, 2004-2014

Technological: Dengue vaccine clinical trials

16 This campaign started in Purkowerto City in Central Java and as of 2004, has expanded to 14 more cities (including Palembang, Cirebon, Solo, Kudus, Surabaya

and Bali) in Indonesia through funding from Rotary International and the Center for Disease Control (US).

Note: From 2014 to 2017, the target incidence rate is from 51/100,000 to 50/100,000.Sources: Ministry of Health Indonesia. Formulir 2, Rencana Kerja Kementerian/Lembaga (Renja-KL) Tahun Anggaran 2014,http://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F21.pdf ; Daftar Program Dan Kegiatan Tahun 2014,http://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/Unit_Reff.pdf

http://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F21.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F21.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/Unit_Reff.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/Unit_Reff.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/Unit_Reff.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F21.pdf


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Public-private partnerships in the dengue vaccine clinical trials give Indonesia advantages in terms of thevalue it puts on virus sovereignty. It is now mandated by the government that all research conducted withvirus samples from Indonesia needs to be conducted with a government research institute – not only tostrengthen technical capacity but also to reinforce Indonesia’s virus sovereignty. In 2012, a Memorandumof Understanding (MOU) on Synergy Research and Development of Vaccines and Drugs and RawMaterials was signed by 16 institutions in academia, business and government. The MOU amplifiesIndonesia’s goals of self-reliance and self-sufficiency particularly in developing Indonesia’s

biopharmaceutical production and strengthening the country’s national pharmaceutical industry byharnessing in-country raw materials (Biofarma 2012). As such, the Eijkman Institute of Microbiology underthe Ministry of Research and Technology, a non-profit, government-funded research institute focused onthe molecular epidemiology, genetics and biological characteristics of dengue in Indonesia and is the mainpartner for multinational pharmaceutical companies in conducting dengue vaccine clinical trials.17

There are numerous sectors involved in the development of dengue treatment and dengue vaccineparticularly pharmaceutical companies and health consumer goods producers, that partner withgovernment institutions and universities18 in Indonesia. Sanofi Pasteur has been collaborating with theEijkman Institute of Microbiology for the development of a dengue vaccine and in conducting clinical trials inIndonesia.19 In October 2014, along with other researchers from the Philippines, Vietnam, Malaysia andThailand, the CYD Study Group and Sanofi Pasteur 20 released the third phase of vaccine efficacy trialresults, which showed that the dengue vaccine is efficacious when given as three injections to childrenaged 2-14 in endemic areas and has a good safety profile (Capeding et al. 2014). In addition, the HDIGroup of Companies in Indonesia conducted clinical trials for a propolis honey-based treatment for denguefrom 2010 to 2014. According to their website, their product HDI Propoelix is already available on themarket and is recommended as a supplement to patients with DHF (HD Indonesia 2015; Osman 2014).These multi-sectoral partnerships, if successful, can fill the gap for a much-needed dengue vaccine in theregion. This presents an opportunity for the Indonesian government to be both a pioneer and beneficiary ofdengue vaccine development.

Environmental: Indonesia Climate Change Trust Fund and climate vulnerability mapping

The Indonesia Climate Change Trust Fund (ICCTF) provides funding for priority sectors, including health. Itwas noted that ICCTF funding is acquired through competitive proposal reviews managed under the UnitedNations Development Programme and the Ministry of National Development Planning Agency(BAPPENAS). The ICCTF serves to attract investment on mitigation and adaptation programmes integratedinto national investment strategies. In 2014, the Environmental Health Directorate of the MOH acquiredICCTF funding to conduct assessments on dengue, dengue haemorrhagic fever and malaria vulnerability toclimate change particularly the impact of humidity, temperature and rainfall on mosquito breeding sites andpatterns in West Sumatra, Jakarta, East Java, Timor, Bali and West Kalimantan.21 One study projected andmapped climate-induced dengue haemorrhagic fever in 20 districts and cities and associated the increasedincidence of DHF with the amount of rainfall and the increase in temperature in these provinces (Haryantoet al. 2014).

The Environmental Health Directorate is responsible for the creation and development of vulnerability mapsas information and advocacy materials on environmental health for local government officials. Localgovernment officials find these useful in terms of crafting policy on climate and health which also providethem with evidence-based policy recommendations such as identifying vulnerable or hotspot areas for

17 This was made possible when in 2006, Indonesia, asserting its virus sovereignty, refused to share samples of the H5N1 bird flu virus with the WHO for

surveillance and vaccine development. This was only resolved in 2011 with the WHO Pandemic Influence Preparedness Framework. This framework established

a pandemic influenza virus sharing mechanism in the access to vaccines and the operationalisation of the Standard Material Transfer Agreement.18

Some university-private sector partnership-based research on dengue treatments are mired with controversy because of perceived lack of transparency and

credibility in the conduct of clinical trials (Sumedi 2013; RIKEN, 2015; Jakarta Post, April 22, 2014; Asian Scientist, January 2, 2014; Melaleuca Alfernifolia

Research 2014; Jakarta Post, January 15, 2015).19

The University of Indonesia’s Medical School, the Hasan Sadikin Hospital -Faculty of Medicine of the Padjadjaran University in Bandung, the School of Medicine

of the Udayana University in Bali are involved in these clinical trials.20 Aside from Sanofi Pasteur, other pharmaceutical companies such as Takeda is set to begin the third phase of its clinical trials, while Novartis, Merck and

GlaxosmithKline are also developing their own vaccine candidates (Research and Markets 2014).

21 Interview with Indonesian officials, Jakarta, 8 December, 2014


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priority interventions.22 Scaling up the creation of vulnerability maps for all provinces will prove useful notonly for local government officials but also for the national government in terms of expanding and targetingsites for adaptation and environmental health initiatives. Climate vulnerability mapping also contributes tothe development of community empowerment tools for dengue prevention and control.23 These tools havebeen utilised for COMBI planning but their success needs to be assessed alongside the communityownership of the core of dengue prevention such as the 3M Plus and the jumantik programme. Increasingpublic awareness through improved health communication strategies not only by public health workers but

also by medical professionals on the risks associated with dengue to their patients are deemed not onlynecessary but can also be a more cost-effective strategy.

Legal: Dengue outbreak reporting system

Reporting a state of emergency for dengue haemorrhagic fever is mandated under Indonesian law. Denguefever and dengue haemorrhagic fever are legally acknowledged as diseases that local government officialscan declare as an ‘extraordinary situation’ or kejadian luar biasa (KLB) status if there is an outbreak thatcan lead to an epidemic (Ministry of Health Regulation No 949, 2004). A KLB can be declared if one of thefollowing criteria is met: (1) emergence of an illness that did not exist before; (2) a two or three-foldincrease in the number of new cases in a month and; (3) a 50 per cent rise in the fatality rate in a particular

period (Aruperes and Susanto 2015). A KLB also requires that a regency or district assess whether itsfinances and human resources can respond to the extraordinary situation.

Weaknesses

Political: Limited public health funding

Varying and limited public health funding influence the amount allocated for dengue prevention and control. Indonesia’s Health Law mandates that 5 per cent of the total national budget be allocated for health butcurrently, health only gets 3.7 per cent (70 trillion rupiah) of the national budget (Dharmawan 2014). In2012, only 39.6 per cent of the total health expenditure came from government spending (World Bank2014). The national government allocated approximately USD130 million in 2013 for its disease control andenvironmental health programmes, under which dengue prevention, control and surveillance falls (SeeFigure 4). The estimated funding needed slightly increased to approximately USD141 million for 2014(Ministry of Health Indonesia 2014).

The Ministry of Health allocated at least six to seven per cent of its budget to disease control andenvironmental health from 2013-2014. However, the estimated budget allocated for 2015-2017 iscomparably less than the budget for 2013-2014, the lowest being that for 2015-2016 which comprisesabout 4.9 per cent of the ministry’s budget. With the decreased allocation for disease control andenvironmental health in 2015, the national budget allocated for arbovirus control that covers three vector-borne diseases - dengue haemorrhagic fever, chikungunya and Japanese encephalitis - increased fromabout USD100,328 in 2013 to about USD712,531 every year from 2014-2017. With these fluctuations in

public funding, it is evident that there is an issue of sustainability and revolving funding sources for dengueinterventions.

22The Environmental Health Directorate has a three-pronged strategy in terms of addressing the impact of climate change on the health sector: scientific studies

and assessments; mapping vulnerabilities; and the development of public information and communication materials. Most of the scientific studies and

assessments in relation to health and climate change had been done in collaboration with the Ministry of Environment as well as in collaboration with scholars

and experts from the University of Indonesia’s Research Centre for Climate Change and the Institut Pertanian Bogor. (Interview with officials from Ministry ofHealth Indonesia by Gianna Gayle Herrera Amul, December 8, 2014)23

Packaged as information kits that focus on the impact of climate and weather patterns on mosquito breeding density, the number of breeding sites and the

needed change in the community’s behaviour towards their environmental health conditions, these tools are useful for planning interventions at the local level.


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Such limited and varied funding is also evident at the local government level. For example, Jambi wasamong the provinces with the highest case fatality rates from 2012-2013 but its case fatality rate wasreduced to 0.90 in 2014 from 2.82 in 2013. This reduction can be attributed partly to the increase in thepublic health expenditure in Jambi – from 39,992 million rupiah in 2013 to 175,601 million rupiah in 2014(Ministry of Health Indonesia 2014). Moreover, Jambi has a USD6 per capita discrepancy to meet thedemand for minimum health services24 – Jambi only spends USD19.13 per capita to meet minimum healthservices but the estimated demand cost for minimum health services is at USD25.17 per capita (Ensor etal. 2012). Jambi’s dengue problem can also be largely associated with its environmental health as biofuelplantations are prevalent in the province and are all-year breeding grounds for Aedes aegypti mosquitoes(Creutzig et al. 2013).

Economic: Gaps in National-Local Health Coverage

There are substantial gaps in national-local health coverage that is exacerbated by considerable challengesin poverty reduction. With more than forty per cent of its population living in multidimensional poverty, andwith health depravity contributing about thirty-five per cent to overall poverty, Indonesia’s poor are in direneed of social protection (UNDP 2012). The national health insurance program or BJPS already coversdengue fever (BPJS 2014). The coverage for dengue-related medical costs is determined through tieredsocioeconomic clusters.25 However, there are problems associated with the supposedly complementarynature of locally-funded health insurance for those not covered by the national program for poorhouseholds (Sumarto et al. 2014). Thus, local government performance in terms of providing universalhealth coverage varies depending on budget capacities and constraints. There are claims at the nationallevel that accountability of local health outcomes rest on local government leaders. However, there is littlediscretion given to local governments over the use of public health funds which are still determined by thecentral government (Heywood and Harahap 2009). Indonesia has 34 provinces, five of which (Aceh,

24 Minimum health services package or the Standard Pelayanan Minimal (SPM) comprises maternal and neonatal care, family planning, infant and child health(including routine health checks and care for children suffering from malnutrition, diarrhoea and respiratory infections) and priority communicable diseases

(tuberculosis, malaria and dengue).

25 Interview with Indonesian officials, Jakarta, 8 December 2014

121.95

130.31

96.22

106.04

116.9

4.9

6.56

3.49

4.04

4.7

1.66

2.38

2.4

2.44

2.43

0 20 40 60 80 100 120 140 160

2013

2014

2015

2016

2017

Figure 7. Al located and Pro jected Publ ic (Ministry of Health) Fundin g for

Disease Contro l and Enviro nm ental Health, 2013-2017, in USD mill io n

Other components of disease control and environmental health

Other components of vector-borne disease control (chikungunya, Japanese encephalitis)

Reduction of DHF incidence

Source: Ministry of Health Indonesia 2014. Accessed January 23, 2015. http://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F23.pdf

http://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F23.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F23.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F23.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F23.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F23.pdfhttp://www.depkes.go.id/resources/download/laporan/rencana-kerja/p2pl/F23.pdf


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Jakarta, Yogyakarta, Papua and West Papua) have greater legislative privileges and a higher degree ofautonomy from the central government.26 The impact of decentralisation on health in Indonesia variesconsiderably in terms of national and local fiscal capacities. Local governments’ priorities will no t always bealigned with national public priorities in terms of health.

Socio-demographic: Rural-to-urban migration and health system deficits

The growth of rural-to-urban migration is a cause for concern as there is consensus among Indonesianhealth officials that dengue is highly attributable to urbanisation. There is local evidence that demographicchanges impact age distribution of cases and period of incidence. A recent study confirmed that there is aclear annual geographical distribution of DHF incidence concentrated in densely populated areas and thatDHF incidence has been increasing in over 15 year olds (Karyanti et al. 2014). This upward shift fromunder five year olds was partly explained by decreasing birth and infant mortality rates since 2003,influenced by rapid urban population growth (Karyanti et al. 2014). Consequently, rapid and uncontrolledurbanisation driven by rural-to-urban migration and high population density also drive the higher incidenceof dengue in Indonesia (Fullerton et al. 2014).

Current rates of urbanisation and population density in Indonesia show no signs of decreasing. At an urbanpopulation growth rate of 2.5 per cent, it is estimated that 65 per cent of Indonesians will be urban residents

by 2025. Indonesia’s population density increased from 107 per km2 in 2000 to 130 per km2 in 2013 (BPSStatistics Indonesia). This figure however does not show how dense Indonesia’s islands are becoming. Among the top provinces with the highest population densities include provinces with the highest dengueincidence particularly Jakarta (15,063/km2), West Java (1,285/km2), Yogyakarta (1,136/km2), Central Java(996/km2), East Java (801/km2) and Bali (716/km2) (BPS Statistics Indonesia 2015). The provinces with thehighest number (more than 100) of dengue deaths from 2012 to 2014 are also concentrated in Java, withCentral Java recording about 182 deaths in 2013, the highest number of dengue-related deaths during thisperiod. This is mainly attributed to Java’s urban population density and uncontrolled urbanisation.

At present, Indonesia’s health system and infrastructure is limited and needs drastic improvement to fulfilimplementation of a universal healthcare system. Indonesia has only 1603 hospitals: 864 are public (MOH,provincial and district) hospitals of which 771 are general hospitals, and only 93 specialist hospitals, and739 private-run hospitals of which 539 are general hospitals and 200 specialist hospitals (Ministry of HealthIndonesia 2015). This means that there is less than 1 hospital per 100,000 people. Consequently, there isapproximately only 1.12 hospital bed per 1,000 people (Ministry of Health Indonesia 2014).

In 2011, the Health Ministry estimated that dengue outbreaks already cost Indonesia about USD 363 millionannually with about USD 40 million in medical expenses (Faizal 2011). This does not cover expenditureson vector control, vaccine research and development, or health personnel costs. Such constraint is furtherexacerbated by the deficit in health infrastructure quantity and quality. Indonesia’s health system remainsinsufficient and inefficient to provide an adequate level of service to a population of about 250 million. Thereare about 9,719 primary health care centres (puskesmas) around the archipelago. The puskesmas havealready integrated dengue prevention and control activities as part of their core functions and have served

as vital nodes for initial diagnosis and dengue case referral to hospitals.27

However, the majority of theprimary health care centres in Indonesia are concentrated in Java because of population density (Figure 5).

26 There was a major transfer of administrative, political and financial authority to the district/municipality in 2001, when the 1999 decentralisation law took

effect. The districts and cities, with their own local parliaments, were given responsibility for several policy areas including health. Provincial governmentsbecame representatives of the central governments, with supervisory and coordinating functions with the revision of the decentralisation laws in 2004. There

are now 399 districts, 98 municipalities, 6,793 sub districts and 79,075 villages.

27 Interview with Indonesian official, Jakarta, 8 December 2014


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Figure 8. Distr ibut ion of Prim ary Health Centres in Indo nesia per Province (as of February 2015)

Source: Ministry of Health Indonesia 2015

Environmental: Under-utilisation of climate vulnerable disease mapping

There is still under-utilisation of climate-related data for a dengue early warning system. Despite therecognition that climate change affects public health and collaboration between the MOH and theMeteorological Climatological and Geophysical Agency (BMKG), few regulations are implemented toaddress the impact of climate change on health like the Health Sector Adaptation Strategy to the Impact of

Climate Change (2011) and the Guidelines for Identifying Health Risk Factors due to Climate Change (2013). BMKG analysis for an early warning system on climate change impact on 10 climate-vulnerablediseases identified by the Ministry of Health, including vector-borne diseases like dengue was proposed asearly as 2010, with a case study of Jakarta (Sasmito et al. 2010). However, it was only in 2014 thatprovincial assessments and the mapping climate vulnerable diseases such as dengue and malaria weremade available through ICCCTF funding.

Opportunities

Political: Positive incentives and multi-sectoral public health interventions

Further expansion of peer awards can institutionalise the 3M Plus programme beyond the public sector. A

good local example of this is Bali’s Healthy City programme which includes dengue-awareness raisingcampaigns and clean and healthy lifestyle (Perilaku Hidup Bersih dan Sehat PHBS) campaigns in marketsthat target housewives, free distribution of abate powder, mosquito larvae eradication program (PSN) andthe jumantik , community health education or Penyuluhan Kesehatan Masyarakat(PKM) and a yearlyperformance-based competition among POKJANAL DBD at the district level (Bali Provincial Government2010). This competition coincides with another for city cleanliness awards, especially in Denpasar. Theawards criteria are based on environmental health indicators including: number of dengue cases andnumber of dengue-related deaths; the participation of residents, young people and women’s associations(PKK, pendidikan kesejahteraan keluarga) in PSN activities; free larvae index and; waste, parks anddrainage management.28 Denpasar’s 2015 target in reducing morbidity from DHF to 500 per 100,000 iscoupled with a free larvae index target (angka bebas jentik) of more than 95 per cent and conducting an

28Monetary awards at the village level range from 2 million rupiah (USD163) to 3.5 million rupiah (USD286); at the district level, from 3 million (USD245) to 11.5

million rupiah (USD 941), and the overall winner from village and district level can be awarded by 20 million rupiah (USD1,638) (City Health Office Denpasar

2013).


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epidemiological investigation within 24 hours of reported cases or outbreaks. According to the DenpasarCity Health Office’s Strategic Plan (2010), these targets are to be accomplished mainly by communityspraying and fogging to prevent mosquito breeding. Denpasar has at least 474 jumantik monitoringresidential areas and advising people to regularly conduct 3M (Jakarta Post , May 9, 2014). These targetswere based on 2009 reported outputs, where the City Health Office of Denpasar (2010) reported achieving93.17 per cent of the free larvae index, 100 per cent reporting of KLBs but only reaching 59.4 per cent of its80 per cent target of communities practicing PHBS.

National and local governments can loop a variety of actors into public and environmental healthinterventions. Some of these actors include public-private research networks, intergovernmental healthorganisations and civil society organisations. Aside from government agency-conducted research, public-private research collaborations can support clinical research and supplement training and education. Anexample is the Clinical Epidemiology and Evidence-based Medicine (EBM-ICE) Network, a medicalresearch network which is composed of representatives from both public and private medical schools andhospitals. Established in 2011 to develop medical education, training and research towards theimprovement of quality health care, clinical research, community health service and health informationsystems, the network has the Ministry of Health, Ministry of Education and Ministry of Research andTechnology as members of its advisory board (Ministry of Health Indonesia 2011). The existence of suchnetworks already provides an important node for regional collaborative efforts to exchange expertise, andshare information in line with the ASEAN Strategic Framework on Health Development.

There is also the Indonesia Research Partnership on Infectious Disease (INA-RESPOND), a collaborationbetween US and Indonesian government institutions and universities towards high quality infectiousdisease clinical research, particularly those prioritised by the Indonesian Ministry of Health: malaria, avianinfluenza, dengue, HIV-AIDS, tuberculosis (MADAT) and neglected infectious diseases. 29 In addition,Indonesia’s major public hospitals, the Dr Cipto Mangunkusumo Hospital (Jakarta), the Dr WahidinSoedirohusodo Hospital (Makassar) and the Dr Sardjito Hospital (Yogyakarta) are among the researchsites of the SEAICRN. The INA-RESPOND is also a network partner of the SEAICRN. The involvement ofINA-RESPOND in a regional network such as the SEAICRN shows the potential for more collaboration inthe region.

The above examples of university-private sector-government collaboration shows that Indonesia alreadyhas existing nodes for multi-level and multisectoral collaboration especially for clinical research. Universitycollaborations and networks need to be encouraged not only for scientific and clinical research but also forbuilding a community of practice that continuously trains experts who can introduce innovations in the field. For example, the Vector and Reservoir Control Research Unit of the National Institute of Health Researchand Development (LITBANGKES), under the Ministry of Health of Indonesia and the Directorate General ofCommunicable Disease Control and Environmental Health collaborate in investigations of dengue anddengue haemorrhagic fever outbreaks in Indonesia. The results of their research are publicly availableonline in the local language however the rate by which these studies are actually shared at the local leveland considered by local policymakers has been minimal. However, it is through these universitycollaborations where standardised, quantitative and qualitative impact evaluation can be developed to

enable policymakers not only to target interventions but also to solidify the evidence that the targetcommunities actually benefit from these interventions. Bridging science, policy and the people togetherwould be one important contribution of university-based collaborations and initiatives.

Given the scarcity of health professionals in Indonesia, several civil society organisations have beensupplementing government awareness raising campaigns on dengue, particularly on the 3M Plusprogramme. The Indonesian Red Cross (Palang Merah Indonesia), particularly its youth arm, aside fromdisaster preparedness and emergency responses in conflict and disaster situations works closely with theJakarta local government on dengue and bird flu prevention (Goodwin and Martam 2014). Muhammadiyah,

29 Its partners include the National Institute of Health Research and Development (NIHRD, LITBANGKES), US National Institutes of Health, National Institute of

Allergy and Infectious Diseases (NIH-NIAID), US Centers for Disease Control and Prevention, the Eijkman Institute for Molecular Biology in Jakarta, researchers

from the University of Airlangga/Dr Soetomo Hospital (Surabaya), University of Diponegoro/Dr Kariadi Hospital (Semarang), University of Gadjah Mada/DrSardjito Hospital (Yogyakarta), Hassanudin University/Dr Wahihdin Sudirohusodo Hospital (Makassar), University of Indonesia/Dr Cipto Mangunkusumo Hospital

(Jakarta), University of Padjadjaran/Dr Hasan Sadikin Hospital (Bandung), University of Udayana/Sanglah Hospital (Bali), Prof Dr Sulianti Saroso Infectious

Diseases Hospital (Jakarta), and the Persahabatan Hospital (Jakarta). For more information, see the INA-RESPOND website: http://www.ina-respond.net/

http://www.ina-respond.net/http://www.ina-respond.net/http://www.ina-respond.net/http://www.ina-respond.net/


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the largest faith-based organisation in Indonesia, has branches in the top provinces with the highestincidence rates. Muhammadiyah’s institutional reach starts from the central, to the provincial, to theregional, to the district to the subdistrict level.30 Much of Muhammadiyah’s activities in relation to dengueare on advocacy and awareness-raising, particularly through its women’s arm – the Aisyiyah. For example,the SITKES Aisyiyah Yogyakarta (College of Medical Sciences) collaborates on awareness-raisingcampaigns with the Eliminate Dengue project in Indonesia. The Muhammadiyah University of Yogyakartaon the other hand has been hosting an annual International Medical Summer School for the past ten years

that focuses on tropical diseases, particularly malaria and dengue fever (Muhammadiyah 2014).

In addition, the WHO in Indonesia provides capacity building from vector control and clinical managementto prevention. It also addresses issues of the co-morbidity of dengue with other diseases, such asJapanese encephalitis which is known to cause sub-clinical infections for dengue patients. The WHO’starget especially for dengue is to reduce morbidity especially in urban areas to reduce case fatality throughbetter clinical disease management. The WHO provides technical support especially to address specifictraining requests on dengue case management and community dengue control from the Ministry of Healthas well as national evaluations or reviews of their dengue control program. Part of this is in collaborationwith the National Institute for Health Research and Development (LITBANGKES) that serves as the WHOCollaborating Centre for Health System Research Management. The Centre is mainly involved in thedecentralisation of health services through training researchers and local government institutions. Nationalhealth officials have been concerned about the impact of decentralisation not only on health but also onenvironmental policies, as responsibilities fall on local governments to continue to implement nationally-initiated programmes, priorities of which can differ from the Ministry of Health.

Moreover, the WHO collaborates at the regional level with ASEAN in the observance of the annual ASEANDengue Day. The WHO in Indonesia emphasises that it is important to look into the dynamics of thedisease which would entail not only better health infrastructure but also better reporting capacities. The ASEAN Dengue Day is organised under the principle of regional information sharing as dengue is a prioritydisease for the Asia Pacific.

Furthermore, the WHO along with the Indonesian Epidemiologists’ Association, local governments and

donors all contributed to the sustainability of the field epidemiology training programme (FETP). This was inline with its objective to improve the capacity of Indonesia’s disease surveillance and response systems.The government then implemented a five-year revitalisation work plan in 2007 to address the requirementsof the revised 2005 International Health Regulations. With a governmental decree, the FETP wasintegrated into the MoH workforce development strategy along with improvements in the curricula, morefield-based epidemiological work and the establishment of an FETP Secretariat. Since 2008, FETPstudents have been actively mobilised for nationwide outbreak investigations for dengue, rabies,leptospirosis and Chikungunya among others.

In this regard, the WHO is thus an important actor not only for awareness raising and capacity building, butalso in ensuring that Indonesia’s decentralisation leads to better health systems and services at the locallevel. The WHO needs to further leverage on its capability to raise dengue to the forefront of the global

national and local health agendas as it did with focusing on vector-borne diseases for the observance ofWorld Health Day in 2014. Dengue is already endemic in more than a 100 countries and the WHO and ASEAN can propose a World Dengue Day to increase awareness of dengue and push for more effectivedengue prevention and control globally. This can also coincide with ASEAN Dengue Day to further promotethe involvement of different sectors and stakeholders.

Economic: Engaging tourists and the private sector

Areas with high tourism rates can leverage on associated economic growth to collaborate with the privatesector and mobilise communities to improve and sustain interventions at the local level. For example, inBali, the hotel industry is increasingly acknowledging their role in dengue prevention and control. InNovember 2014, the Bali Hotels Association, the Ministry of Health and Kyoto University held a workshop

30 It has an executive General Health Service Council at the Central level, and operates 71 general hospitals, 49 maternity clinics, 117 public health service

centres for women and children, 47 polyclinics, and other health services across Indonesia (Muhammadiyah 2014).


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on dengue control. The workshop concluded with standard operating procedures (SOPs) for vector controlin the hospitality industry which included hotel guest advisory on personal protection from mosquitoes,cooperating with the government and communities and other organisations in keeping surroundings clean,3M Plus, reducing mosquito larvae breeding grounds and fogging. It was noted that there is a growinginterest among hotel industry representatives to collaborate with universities and the government to be keptinformed and updated on cost-effective source reduction and vector control strategies. 31 There areregulatory issues in the use of imported and local insecticides identified during this workshop and BTI

(bacillus thuringiensis israelensis) was highly recommended to eradicate mosquito larvae but ‘regulationsand rules on the use of BTI in Indonesia is still being drafted by the Ministry of Health (PHRI Bali 2014).’Such multi-sectoral partnerships are an opportunity to explore especially in major tourist areas.

Tourism targets can be aligned with improving the health infrastructure and creating job incentives forlocals in the health or medical tourism sectors. This can also be an incentive for locals to stay in Indonesiafor medical treatment. The Ministry of Health and Ministry of Tourism already signed an agreement for thedevelopment of health tourism in Indonesia which will include both public and private stakeholders (hospitalrepresentatives, spa providers, health associations) to create a work plan for the Indonesia Wellness andHealthcare Tourism working group. The government has already identified Bali, Jakarta, Makassar andManado as the four hot spots to pioneer health tourism development (International Medical Travel JournalNews, January 4 2013).

This shows that the private sector is increasingly aware of the dengue burden on general public health andthe economy especially in terms of productivity. However, private sector involvement in many awarenessraising activities remains short-term and lacks impact evaluation. Both the government and civil societyorganisations can push for the private sector to integrate dengue prevention and control in their corporatesocial responsibility strategies. This can be promoted by the co-benefits of working towards dengueprevention to avoid associated productivity losses but also as a holistic public health goal.

In addition, private-sector-led dengue fever insurance mechanisms can complement if not fully integrateinto the national health insurance system. For example, combining social security mechanisms and micro-entrepreneurship, the Indonesian Midwives Association (IMA) through the Bidan Delima programme

partnered with ACA Insurance for a micro-entrepreneurship venture for accredited midwives to offer theDengue Fever Insurance card that can cover up to USD 100 to USD 200 of medical costs with a premiumof USD1 to USD5 (Centre for Health Market Innovations; Reis 2012). This programme is spearheaded andsupported by the USAID since 2003, aimed at improving midwifery services in Indonesia. Given thatuniversal health coverage is still in progress, such low-cost supplementary social security or healthinsurance mechanisms can lessen health expenses.

Technological: Biological control of dengue and awareness raising

Moreover, the Faculty of Medicine of the University of Gadja Mada in Yogyakarta is involved in thebiological control project, Eliminate Dengue Indonesia, supported by the Tahija Foundation. Since 2011, ithas been in collaboration with Monash University and the University of Melbourne in Australia. It was only

in January and December 2014 that field trials began in two sites in Yogyakarta, using adul

Documents

NTS Report No 2